Behaviour Centred Care versus Person Centred Care: The Challenge

of BPSD Management

Dr Lisa Clinnick

Australian Catholic University

School of Nursing, Midwifery & Paramedicine

Discussing

• What is person centred care and can it be achieved?

• Explore PCC and BCC focusing on the use of psychotropic medications in residential aged care.

• Key elements of PCC

• Nurse Behaviour Assistant – mobile application.

Person Centred CareDefining PCC

-Kitwood (1997) – to be a person meant to have personhood.

-described by others as • maintaining personhood despite declining cognitive ability;

• collecting and using personal experiences of life and relationships to individualised care;

• prioritises relationships as much as care tasks;

• involve family members in care and shared decision making .

Person Centred Careas “…the need for a recognition of, and connection with, the person, a focus on the person’s strengths and goals, an interdisciplinary approach, and a recognition of the centrality of relationships”.

(Nay et.al., 2014).

Barriers• Despite its intuitive appeal, the philosophy of

resident-centred care has not yet been widely embraced.

• Resistance stems from both the institutional system and the direct care provider.

Barriers• obstacles include –

– regulatory and sanction pressures

– the fear of litigation if one deviates from tight conformation to uniform protocols

– high staff turnover rates which make it difficult for staff to get to know and develop relationships with residents,

– and a lack of clear standards to guide the provision of more individualized, humanistic care .

– Staff convenience

– Facility/staff culture

BCC vs PCC – psychotropic medsBehaviour Centred Care Person Centred Care

Psychotropic medication as 1st option Use non pharmacological intervention 1st

Quick easy fix Need to know the resident

Stopped behaviour ‘now’ Effective and calms the resident

No special skill required Increases staff moral & satisfaction

Nurse controlled the situation Promotes resident autonomy

Lack team work Interdisciplinary approach

No family relationship or involvement Family/resident involved as partners

Institutionalised culture Nurse advocate

25%-50%

Rate of NH

residents on

psychotropic

medication

(1988)

47.7%

rate of Sydney NH

residents receiving

psychotropic medication

(2006)

UK 2009

Dementia Framework

submission –

“estimated that we are

treating 180,000 people with

dementia with antipsychotic

medication across the

country per year. Of these, up

to 36,000 will derive some

benefit from the treatment”

60%

of residents receive one

psychotropic medication

37%

receive two

11%

receive three or more.

(1988)

20%

The number of residents

receiving psychotropic

medications who did not have

a diagnosis (1994)

2003 Helsinki

study

79.9% of residents

prescribed

psychotropic

medications

Psychotropic medications use in RACF• “Side effects of all benzodiazepines include

excessive sedation, psychomotor slowing, cognitive impairment, confusion, forgetfulness, morning “hang-over” effect, ataxia and falls”

• the overall side effect profile of both typical and atypical antipsychotics is vast. Side effects include increased risk of falls, sedation, orthostatic hypotension, anticholinergic effects, insomnia and weight gain to name a few.

Research method

Research question Exploring nurses decisions when administering psychotropic medications to nursing home residents

Methodology• Qualitative research – Grounded Theory

Data Collection• X2 NH completed• Interviews – RN’s & EEN• Participatory observation – work with the nurses• Field work – 6-9 months each NH

findings

• Nurses wanted to provide PCC but provided BCC.

The nurses –

Customs

Knowledge

Relationships

influenced the decision making outcome

Customs

• What is a custom –

– an established and socially accepted practice.

– Assists to regulate the social group.

The custom was to administer psychotropic medications as first line management of unmet need behaviours.

Customs - theme

• Controlling the residents behaviourWe’d use antipsychotic medication as we call it. It helps to control the behaviour of those residents who are very hard, you know, very, very – who’ve got dementia and very, very hard to control. (Participant 1, p. 1)

• Convenience Oh well they (the nurse) know it’s going to shut them up (Participant 3, p. 4)

• Accepted practice

• Responsibility of role

Knowledge• Nurses’ knowledge of psychotropic medication

and chemical restraint

• Knowledge of nursing interventions and alternative strategies

• Knowing the resident - nursing assessment and evaluation

• Type of resident receiving psychotropic medication as chemical restraint

Relationships• Rights – staff and residents

• Health professionals relationships

• Family involvement

How can we move towards a PCC model?

Successful implementation of a PCC model needs –

• Cultural change including

– Staff empowerment – challenge accepted practices/customs/attitudes

– Effective Teamwork – health professionals and families

– Strong leadership and role modelling.

– Ongoing education and up-skilling

– Family/resident relationships and partnerships

Nurse Behaviour AssistantProject Aim

• to identify an appropriate approach toward the provision of tools that could be helpful to nurses when making assessments and choosing BPSD intervention strategies when attending to a resident in a short time frame.

• be practically deployed

• encourage a decision maker to exercise discretion

• Developed NBA – Nurses Behavioural Assistant innovative and sophisticated psychologically-based mobile application and web-based system.

Ripple Down Rules• using concepts of discretion from

jurisprudence helped to identify the ripple down rules

• A key feature of the RDR approach is that the rule base can be initially deployed with a relatively small number of rules drawn from best practice principles for assessment and intervention selection, and relatively easily have new rules added that act as exceptions to the first entered rules for specific situations.

Findings & Future• Very well accepted application – positive feedback

• More of a focus on the NBA as a reporting as well as learning system, instead of an intervention system for problem behaviours.

• PCA and volunteers who have less formal training to be used in future trials.

• Greater staff involvement over a longer trial period, suggested up to 3 months.

• The use of all staff members (nursing, pca and voluntary) and all resident’s one facility to ensure all events are captured.

Conclusion

PCC is the ideal care model in aged care.

“Excellence is not a destiny, it is a continuous journey that never ends” Brian Tracey